POSTPARTUM PSYCHIATRIC

DISORDERS

Mbundire Farai Happy

farairuth1@gmail.com
OVERVIEW
• Many females experience a wide range of overwhelming emotions such as
anticipation, excitement, happiness, fulfillment, as well as anxiety,
frustration, confusion, or sadness/guilt during pregnancy and postpartum
period.
• The postpartum period makes them highly vulnerable to various psychiatric
disorders.
• Traditionally postpartum psychiatric disorders are classified as postpartum
blues, puerperal psychosis, and postnatal depression
• Perinatal mental illness is largely under-diagnosed and can have far
reaching ramifications for both the mother and the infant.
• Early screening, diagnosis, and management are very important and must
be considered as mandatory part of postpartum care.
EPIDEMIOLOGY
• Puerperal psychosis is observed in 1–2/1000 childbearing women
within the first 2–4 weeks following delivery.
• Puerperal psychosis is seen as early as 2–3 days following delivery.
• Postpartum depression (PPD) is observed in 10–13% of new mothers,
and
• Postpartum blues, is seen in 50–75% of postpartum women.
• Postpartum psychiatric syndromes are seen more commonly (81%) in
patients below 25 years of age.
ETIOLOGY

• Biological factors
• Pathogenesis of PP has a strong biological element as the onset is abrupt in
nature.
• The early postpartum period is characterized by a marked decrease in
gonadal steroids.
• There is a considerable decrease in the levels of progesterone between the
first and second stages of labor, and estrogen levels drop suddenly
following the expulsion of the estrogen-secreting placenta.
• Estrogen primarily affects the monoaminergic system, especially serotonin
and dopamine; influencing affective symptoms and psychotic symptoms
respectively.
Psychosocial factors

• Pregnancy and the transition to motherhood give birth to a variety of

psychological stressors.
• A woman has to adjust to changes in her body image, her relationships
with her husband and family members, her responsibilities and the
manner in which she is perceived by the society.
Risk factors associated with postpartum disorders

• The risk factors associated with the development of postpartum disorders are:
➢Primigravida
➢ unmarried mother
➢ cesarean sections or other perinatal or natal complication
➢ past history of psychiatric illness, especially past history of anxiety and
depression
➢ family history of psychiatric illness, especially mother and sister having
postpartum disorder
➢ previous episode of postpartum disorder
➢stressful life events especially during pregnancy and near delivery
➢ history of sexual abuse
➢vulnerable personality traits and social isolation/unsupportive spouse
CLINICAL FEATURES

• Earlier postpartum disorders were classified as: (i) Postpartum blues

(PBs), (ii) Post partum depression (PD) (iii) Puerperal psychosis (PP).
• This was an oversimplification. However, in addition to these, there are
miscellaneous groups of anxiety and stress-related disorders occurring in
the puerperium.
• In recent times, postpartum disorders have been classified into five major
categories:
• (i) PBs, (ii) PPD, (iii) PP, (iv) postpartum post-traumatic stress disorder
(PTSD), and (v) postpartum anxiety and obsessive compulsive disorder
(OCD).
• The characteristics of each postpartum disorder are described below
Postpartum blues

➢PBs, also known as “baby blues” or “maternity blues,” is a phase of emotional lability
following childbirth, characterized by frequent crying episodes, irritability, confusion,
and anxiety.
➢“Baby blues” are very common and experienced by most of the women to some extent.
➢It is observed to be as high as 40–85%.
➢The symptoms arise within the first 10 days and peak around 3–5 days.
• Generally symptoms of PB do not interfere with the social and occupational
functioning of women.
• PB is self-limiting with no requirement for active intervention except social support
and reassurance from the family members.
• PB can be attributed to changes in hormonal levels of women, further compounded by the
stress following delivery. However, PBs persisting for more than 2 weeks may make
women vulnerable to a more severe form of mood disorders.
Postpartum depression

➢PPD is the most common psychiatric disorder observed in the postpartum

period.
➢PPD is generally difficult to distinguish from depression occurring at any
other time in a women's life.
➢However, in PPD the negative thoughts are mainly related to the
newborn.
➢It is seen in 10–15% of postpartum women and, in addition to postpartum
time specifier, the diagnostic criteria is difficult to differentiate from that of
major depressive episode characterized by :
➢pervasive depressed mood,
➢disturbances of sleep and appetite,
➢low energy, anxiety, and suicidal ideation.
CONTI…
➢Additionally feelings of guilt or inadequacy about the new
mother's ability to care for the infant, and a preoccupation with
the infant's well-being or safety severe enough to be considered
obsessional.
➢Onset can range from few days to few weeks following delivery,
generally in the first 2–3 months following childbirth.
➢ History of major depression increases the risk for PPD by 25%, and
past history of PPD increases the risk of recurrence to 50%.
Case Vignette
• Sheela was a 30 year-old mother of four children who had been
married for eight years. She lived with her husband and in-laws in a
small village. She had given birth to her fourth child three months
previously. Her pregnancy and labor had been uneventful, and an
untrained traditional midwife helped conduct the home delivery.
Because pregnancy was viewed in her village as a normal occurrence
that did not require any medical attention, Sheela did not receive any
antenatal or postnatal care. For a month after the birth, Sheela felt
normal, but then she began to exhibit unusual behavior. She became
reclusive and stopped speaking to anyone at home, losing interest in
her daily activities and ceasing to care for her children. The rest of the
people in her family, however, were busy with their own lives and
seemed indifferent to her condition.
C0NTI…
• One day, when all of her family members had gone to the fields to
work, Sheela set herself on fire and walked out of the house covered
in flames. Some neighboring men saw her and smothered the flames
with blankets, and one of them ran to get her family from the fields.
They called an auto rickshaw to take her to the hospital, where Sheela
was admitted to the burns unit. She had sustained 63% superficial
and deep burns. Eight days after admission, she died of shock and
septicemias.
Questions for students
• What were the social, economic, and medical factors that contributed
to Sheela’s death?
• What could have been done to prevent it?
Postpartum psychosis

➢PP has an acute and abrupt onset, usually observed within the first 2 weeks
following delivery or, at most, within 3 months postpartum, and should be regarded
as a psychiatric and obstetrical emergency.
➢The presence of a psychotic disorder affects the prenatal and postpartum care adversely.
➢Past history of psychosis with previous pregnancies, history of bipolar disorder, family
history of psychotic illness (e.g., schizophrenia or bipolar disorder) are some of the major
risk factors for the development of PP.
• Most commonly symptoms include:
• Elation
• lability of mood
• rambling speech
• disorganized behavior
• and hallucinations or delusions.
CONTI…
➢However, presentation and course of PP may be more diverse and complex, with
transient or alternating episodes of delusions of guilt, persecution, auditory
hallucinations; delirium-like symptoms and confusion; and excessive activity.
➢ At times, delusions revolves around the infant, especially that the infant is
possessed, has special powers, is divine, or is dead.
➢ Infanticide and suicide are observed in 4% and 5% of the women suffering from
PP respectively.
➢Enquiring about suicidal and infanticidal thoughts is crucial during the assessment
of women suffering from PP.
CASE VIGNETTE
• After delivering a healthy baby by caesarean section, Ms. A went
home on postpartum day 4. Two days later, her husband called her
physician because he was worried about her: she had been acting
“strange” since coming home from the hospital; she worried about
the baby’s well-being and was constantly asking her husband if the
baby was OK. She became agitated and delusional, and her husband
brought her to the emergency room. On first evaluation, Ms A was
disorganized and extremely agitated; she was unable to focus on her
current presentation or even acknowledge that she had recently
delivered a baby. The pregnancy had been planned, and there had
been no complications. She had no personal psychiatric history, but
the history revealed that her mother suffered from depression and
that she had family members who had psychiatric issues, but details
were unknown (Monzon, Scalea.,& Pearlstein,2014).
CASE VIGNETTE FROM THE ECHOS FINAL EXAMINATION
PAST PAPER-NOVEMBER, 2018

• A 25-year-old woman delivers a healthy baby boy by caesarean section.

She notes over the next week that she has become irritable and is not
sleeping very well. She worries that her child will die and fantasizes that if
the child died, she would kill herself as well. She reports not being able to
sleep, and has lost 5 kg within 1 week. Over the course of the following
week, she begins to investigate might commit suicide and calls a friend to
see whether the friend will babysit so that the woman will not be leaving
the child alone should this occur. Which of following is the most likely
diagnosis?
a. Postpartum depression
b. Postpartum psychosis-schizophreniform
c. Postpartum blues
d. Postpartum bipolar disorder-mania
Postpartum posttraumatic stress disorder

• Many studies have shown the incidence of postpartum PTSD to be

around 5.6%.
• It is generally characterized by tension, nightmares, flashbacks
and autonomic hyperarousal that can continue for some weeks or
months, and may recur toward the end of the next pregnancy.
• This can also result in secondary tocophobia (Rai,Pathak., & Sharma,
2015).
Anxiety disorders specific to the puerperium

• Many studies have observed that postpartum anxiety disorders are

under-diagnosed and are in fact more common than PPD.
• De Armond observed that fear of cot death can reach up to a level of
pathological degree.
• The most common feature is nocturnal vigilance characterized by the
mother lying awake listening to the infant's breathing, and frequent
checking resulting in sleep deprivation.
• Many mothers are excessively worried and preoccupied about the
health and safety of their children which is known as “maternity
neurosis (Rai,Pathak., & Sharma, 2015).
Obsessions of child harm

• Women diagnosed with postpartum onset of major depression may

have repetitive, intrusive thoughts related to something occurring to
the baby associated with compulsive checking behavior.
• Postpartum onset of OCD can occur during gestation or within 6
weeks following delivery.
• The theme of the obsessions is frequently related to
thoughts/gruesome images of harming the baby
DIAGNOSIS OF POSTPARTUM PSYCHIATRIC DISORDERS

➢Postpartum psychiatric disorders have largely been under-diagnosed,

reiterating the fact that routine screening during postpartum clinic
visits should form an integral part of the assessment.
➢Use of a population-specific screening tool such as the “Edinburgh
Postnatal Depression Scale,” and the “Mood Disorder
Questionnaire” can improve awareness of healthcare providers
and aid in the early diagnosis of postpartum psychiatric disorders.
➢Studies employing screening procedures have reported considerable
increases in rates of detection of postpartum psychiatric disorders
(Rai,Pathak., & Sharma, 2015).
CONTI…
• Laboratory investigations and thorough physical examination should
be done to exclude organic etiology.
• Sometimes rare medical conditions, such as frontotemporal
dementia or frontal lobe tuberculoma, and Sheehan syndrome can
mimic postpartum psychiatric disorders.
• Important tests include a complete blood count, electrolytes, blood
urea nitrogen, creatinine, glucose, Vitamin B12, folate, thyroid
function tests, calcium, urinalysis and urine culture in the patient
with fever; and a urine drug screen.
CONTI…
• A careful neurological evaluation is mandatory including a brain scan
(cranial computerized tomography or magnetic resonance imaging) to
rule out the presence of a stroke related to ischemia (vascular
occlusion) or hemorrhage (due to uncontrolled hypertension, ruptured
arteriovenous malformation, or aneurysm)
TREATMENT OF POSTPARTUM PSYCHIATRIC DISORDERS

• The treatment of PPDs is generally holistic and includes

1. Reassurance
2. familial and social support
3. psychoeducation, and in some cases
4. psychotherapy and/or
5. pharmacologic treatment.
Nonpharmacological treatment

➢Individual psychotherapy is an integral part of treatment, especially for females finding it

difficult adjusting to motherhood and/or apprehensions about new responsibilities.
➢ Psychoeducation and emotional support for the partner and other family members are
important. Patient and the family members should be involved in the formulation of the
treatment plan.
➢Respite care services should be recommended especially at night to minimize the patient's
sleep disruption. In some cases, interpersonal therapy (IPT) might be beneficial.
➢IPT is shown to result in greater reduction in depressive symptoms and improvement in
social adjustment.
➢In cases of PP, separation from the infant might be necessary.
➢Reassurance and emotional support toward the mother can boost the self-esteem and
confidence of the mother.
➢Peer support and psychoeducation about PP are important interventions. Sometimes,
group psychotherapy may also be helpful.
Pharmacotherapy

➢In moderate to severe depression and PP, medication becomes necessary.

➢Safety and hazards of use of psychotropic medications during lactation
should be addressed.
➢The amount of medication to which an infant is exposed depends on several
factors like, maternal dosage of medication, timing and frequency of
dosing, rate of maternal drug metabolism, and metabolism of the
ingested drug in the infant.
➢Peak concentrations in breast milk are attained 6–8 h after ingestion of
medication. Therefore, breastfeeding can be restricted to times when the
breast milk drug concentration is lowest, that is, just before or after
taking medication
Antidepressants

• Pharmacologic treatment studies for PPD are few and include one
double-blind study demonstrating the efficacy of fluoxetine or
cognitive-behavioral therapy for major or minor depression.
• One open study each for sertraline, venlafaxine, and fluvoxamine.
Approximately, 60% of mothers initiate nursing, and most of the
antidepressants are excreted into breast milk.
• Sertraline, paroxetine, and nortriptyline may be the preferred
choices for nursing women.
• However, the total number of cases reported for any given medication
is small, and concern for infant safety must be considered.
Antipsychotics

➢Atypical antipsychotics are often first-line choices for psychosis and

mania because of their tolerability.
➢On the basis of a recent review of data on adverse effects in infants,
olanzapine and quetiapine were considered the most acceptable.
➢Chlorpromazine, haloperidol, and risperidone were classified as
possible with breastfeeding, with medical supervision.
➢Breastfed infants must be carefully observed for hydration status,
excessive sedation, feeding difficulties, and failure to gain weight, which
are possible signs of drug toxicity, and inform mothers to contact their
physicians when they observe such symptoms.
➢Physicians who prescribe medications to breastfeeding mothers could limit
infant drug exposure by choosing the lowest effective dose, avoiding
polypharmacy, and dividing daily doses to reduce peak concentrations.
Lithium

➢Lithium is an important medication for the management of PP.

➢Monitoring of lithium levels, thyroid and renal function, and adequate hydration is
mandatory during the use of lithium.
➢The use of lithium for breastfeeding mothers has generally been discouraged
by the American Academy of Pediatrics (AAP) because of concerns regarding
secretion of the drug through breast milk.
➢Plasma levels in the infant may exceed 10% of the mother's plasma levels, causing
toxicity in the infant especially in cases of dehydration.
➢ Lithium has been effective in decreasing relapse rates after subsequent
pregnancies, although it is not clear if lithium should be restarted during
pregnancy or immediately after parturition.
➢A recent study suggests that lithium prophylaxis may be more useful in
women who only have a past history of PP than in women with bipolar
disorder who have had mood episodes outside the postpartum period as well.
Anticonvulsants

➢Valproic acid or carbamazepine may be used to manage PP.

➢The AAP reported that both these drugs were compatible with
breastfeeding.
➢Lamotrigine is Food and Drug Administration-approved for bipolar
depression, but no studies have examined its efficacy in PP.
➢It is unlikely to be used in the acute treatment phase since its titration
takes weeks, but it may have a role in maintenance treatment.
Lamotrigine may be used with caution because high plasma levels
of the drug have been found in breastfeeding infants.
Benzodiazepines

➢Benzodiazepines may have a role in the acute treatment of PP.

➢Intramuscular lorazepam and haloperidol can be used to achieve rapid
tranquilization.
➢ Once the patient becomes more stable, oral agents can be used.
➢However, benzodiazepines are not recommended as monotherapy for PP.
➢In a study of 51 women with first-onset psychosis in the postpartum period,
67% achieved remission with a combination of lithium, antipsychotics,
and benzodiazepines;
➢18% with antipsychotics and benzodiazepines; and 6% with
benzodiazepines alone.
Electroconvulsive therapy

➢Electroconvulsive therapy (ECT) can yield rapid symptomatic

improvement in mothers with PP or severe PPD, but it may be
challenging for women who have not previously received any
psychiatric treatment to accept this treatment option.
➢The only risks of ECT to a breastfeeding infant are the medications
given for anesthesia and muscle relaxation, but since these
medications are short-acting, it is expected that there is minimal
transfer to the infant.
Clinical Vignette for students from the Intermediate
Examination past paper (ECHOS, June 2019).
• Mwangala, a 26 year old woman, had recently given birth and has no
history of psychiatric illness. She is admitted to your facility two
weeks after delivery because of abnormal behavior.
a. What are two possible differential diagnoses? ( 2 MARKS)
b. Give reasons for each of your differential diagnoses (4 marks)
c. Manage Mwangala according to the differential diagnoses you
made (9 Marks).
d. Outline the 5 points you will include in your psychoeducation to
Mwangala’s husband. (5 Marks).
REFERENCES
• Garg,B.S.(2015). Case Study: Postpartum Depression. Retrieved from
http://thenetworktufh.org/wp-content/uploads/2015/10/Postpartum-
Depression-Case-Study.pdf on 15/08/19.
• Monzon, C. Scalea,T.L.d,& Pearlstein.(2014). Postpartum Psychosis:
Updates and Clinical Issues. Retrieved from
https://pdfs.semanticscholar.org/650e/9eabaae334a72a524b13792e12a8ffb3
e106.pdf on 15/08/19.
• Rai,S., Pathak,A, & Sharma,I.(2015). Postpartum psychiatric disorders:
Early diagnosis and management. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4539865/ on 15/08/19.